HEALTH SERVICES AND DELIVERY RESEARCH

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1 HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 14 MAY 2014 ISSN Being a manager, becoming a professional? A case study and interview-based exploration of the use of management knowledge across communities of practice in health-care organisations Mike Bresnen, Damian Hodgson, Simon Bailey, Paula Hyde and John Hassard DOI /hsdr02140

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3 Being a manager, becoming a professional? A case study and interview-based exploration of the use of management knowledge across communities of practice in health-care organisations Mike Bresnen, 1 * Damian Hodgson, 1 Simon Bailey, 1 Paula Hyde 1,2 and John Hassard 1 1 Manchester Business School, University of Manchester, Manchester, UK 2 Durham University Business School, Durham, UK *Corresponding author Declared competing interests of authors: none Published May 2014 DOI: /hsdr02140 This report should be referenced as follows: Bresnen M, Hodgson D, Bailey S, Hyde P, Hassard J. Being a manager, becoming a professional? A case study and interview-based exploration of the use of management knowledge across communities of practice in health-care organisations. Health Serv Deliv Res 2014;2(14).

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5 Health Services and Delivery Research ISSN (Print) ISSN (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) ( Editorial contact: nihredit@southampton.ac.uk The full HS&DR archive is freely available to view online at Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: Criteria for inclusion in the Health Services and Delivery Research journal Reports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. HS&DR programme The Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services. For more information about the HS&DR programme please visit the website: This report The research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 09/1002/29. The contractual start date was in September The final report began editorial review in March 2013 and was accepted for publication in September The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report. This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Published by the NIHR Journals Library ( produced by Prepress Projects Ltd, Perth, Scotland (

6 Health Services and Delivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Public Health and Primary Care, University of Oxford, UK NIHR Journals Library Editor-in-Chief Professor Tom Walley Director, NIHR Evaluation, Trials and Studies and Director of the HTA Programme, UK NIHR Journals Library Editors Professor Ken Stein Chair of HTA Editorial Board and Professor of Public Health, University of Exeter Medical School, UK Professor Andree Le May Chair of NIHR Journals Library Editorial Group (EME, HS&DR, PGfAR, PHR journals) Dr Martin Ashton-Key Consultant in Public Health Medicine/Consultant Advisor, NETSCC, UK Professor Matthias Beck Chair in Public Sector Management and Subject Leader (Management Group), Queen s University Management School, Queen s University Belfast, UK Professor Aileen Clarke Professor of Public Health and Health Services Research, Warwick Medical School, University of Warwick, UK Dr Tessa Crilly Director, Crystal Blue Consulting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Elaine McColl Director, Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, UK Professor William McGuire Professor of Child Health, Hull York Medical School, University of York, UK Professor Geoffrey Meads Professor of Health Sciences Research, Faculty of Education, University of Winchester, UK Professor Jane Norman Professor of Maternal and Fetal Health, University of Edinburgh, UK Professor John Powell Consultant Clinical Adviser, National Institute for Health and Care Excellence (NICE), UK Professor James Raftery Professor of Health Technology Assessment, Wessex Institute, Faculty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Kleijnen Systematic Reviews Ltd, UK Professor Helen Roberts Professorial Research Associate, University College London, UK Professor Helen Snooks Professor of Health Services Research, Institute of Life Science, College of Medicine, Swansea University, UK Please visit the website for a list of members of the NIHR Journals Library Board: Editorial contact: nihredit@southampton.ac.uk NIHR Journals Library

7 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Abstract Being a manager, becoming a professional? A case study and interview-based exploration of the use of management knowledge across communities of practice in health-care organisations Mike Bresnen, 1 * Damian Hodgson, 1 Simon Bailey, 1 Paula Hyde 1,2 and John Hassard 1 1 Manchester Business School, University of Manchester, Manchester, UK 2 Durham University Business School, Durham, UK *Corresponding author Background: Understanding how managers in the NHS access and use management knowledge to help improve organisational processes and promote better service delivery is of pressing importance in health-care research. While past research has examined in some depth how managers in the NHS perform their roles, we have only limited understanding of how they access management knowledge, interpret it and adapt and apply it to their own health-care settings. Objectives: This study aims to investigate how NHS middle managers encounter, adapt and apply management knowledge in their working practices and to examine the factors [particularly organisational context, career background and networks of practice (NoPs)/communities of practice (CoPs)] which may facilitate or impede the acceptance of new management knowledge and its integration with practice in health-care settings. Our research was structured around three questions: (1) How do occupational background and careers influence knowledge receptivity, knowledge sharing and learning among health-care managers? (2) How do relevant CoPs enable/obstruct knowledge sharing and learning? (3) What mechanisms are effective in supporting knowledge receptivity, knowledge sharing and learning/unlearning within and across such communities? Design and setting: Three types of NHS trust were selected to provide variation in organisational context and the diversity of services provided: acute, care and specialist foundation trusts (FTs). It was expected that this variation would affect the knowledge requirements faced by managers and the networks likely to be available to them. To capture variation amongst managerial groups in each trust, a selection framework was developed that differentiated between three main cohorts of managers: clinical, general and functional. Participants: After initial interviews with selected key informants and Advisory Group members, the main empirical phase consisted of semistructured interviews combined with ethnographic observation methods. A purposive, non-random sample of managers (68 in total) was generated for interview, drawn from across the three trusts and representing the three cohorts of managers. Interviews were semistructured and data was collated and analysed using NVivo 9 software (QSR International, Warrington, UK). Main outcome measures: The analysis was structured around four thematic areas: context (institutional and trust), management (including leadership), knowledge and networks. The research underlines the challenges of overcoming fragmentation across a diffuse managerial CoP in health care, exacerbated by the effects of organisational complexity and differentiation. The research highlights the importance of Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

8 ABSTRACT specific training and development initiatives, and also the value of NoPs for knowledge sharing and support of managers. Results: The main findings of the research stress the heterogeneity of management and the highly diverse sources of knowledge, learning, experience and networks drawn upon by distinct management groups (clinical, general and functional); the particular challenges facing general managers in establishing a distinct professional identity based around a coherent managerial knowledge base; the strong tendency for managerial knowledge particularly that harnessed by general managers to be more home grown (localised) and experiential (as opposed to abstract and codified); and the tendency for this to be reinforced through the difficulties facing general managers in accessing and being actively engaged in wider networks of professionals for knowledge sharing, learning and support. Conclusions: Management in health care is a complex and variegated activity that does not map onto a clear, unitary and distinct CoP. Improving flows of knowledge and learning among health-care managers involves taking account not just of the distinctiveness of managerial groups, but also of a number of other features. These include the complex relationship between management and leadership, alternative ways of bridging the clinical managerial interface, the importance of opportunities for managers to learn through reflection and not mainly through experience and the need to support managers especially general managers in developing their networks for knowledge sharing and support. Building on the model developed in this research to select managerial cohorts, future work might usefully extend the research to other types of trust and health-care organisation and to larger samples of health-care managers, which can be further stratified according to their distinct occupational groups and CoPs. There is also scope for further ethnographic research that broadens and deepens the investigation of management using a range of observation methods. Funding: The National Institute for Health Research Health Service and Delivery Research programme. vi NIHR Journals Library

9 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Contents List of tables...xi List of figures...xiii List of abbreviations....xv Plain English summary... xvii Scientific summary...xix Chapter 1 Introduction 1 Background to the research 1 Aims and objectives 1 Research context 2 Locating health-care management 2 Knowledge, networks, community and identity 3 Research approach 4 Report structure 5 Chapter 2 Research methodology 7 General approach to the research 7 Research philosophy and methodological choices 7 Design of the study 8 Sample of organisations 8 Identifying managerial cohorts 9 Research process and schedule of activities 11 Project initiation 11 Phase 1: key informant interviews 11 Phase 2: ethnographic study via interviews and non-participant observation 12 Write-up 12 Selection of phase 2 interviewees 12 Character of phase 2 sample 13 Methods of data collection and analysis 14 Phase 2 non-participant observations 14 Data coding and analysis 15 Presentation of empirical data 17 Chapter 3 The institutional and organisational context for National Health Service management 19 Introduction 19 The institutional context of the study 19 Changing policy and management context 20 Consequences for managers and management 21 Management and leadership development in the NHS 22 Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 CONTENTS The case study trusts: organisational context 24 Acute trust 27 Care trust 30 Specialist trust 32 Summary 35 Chapter 4 Management 37 Introduction 37 Managing identities 37 Middle management 38 Managers and professionals 38 Management and leadership 39 The clinical managerial interface 43 Management responsibilities and skills 47 Summary 52 Chapter 5 Knowledge 53 Introduction 53 Aspects of knowledge 53 Professional norms, values and practices (encultured knowledge) 54 The influence of clinical knowledge 55 The influence of specialist knowledge 56 Management tools and techniques (encoded knowledge) 56 Management processes and systems (embedded knowledge) 57 Experience and experiential learning (embodied knowledge) 59 The value of managerial and clinical experience 59 The importance of experiential learning 61 Learning from others 61 Evaluating experience and experiential learning 62 Formal management training and development views and prospects 64 Educational qualifications and professional accreditation 64 The Graduate Management Training Scheme 66 Formal training and development 67 Evaluating formal training? 68 Summary 71 Chapter 6 Networks and networking 73 Introduction 73 Understanding networks in health care 73 Varieties of networks 75 Who networks and why? 76 Networking for knowledge 78 Networking for support 80 Networking for career advancement 81 Networking for influence 82 Complementarity of networking 83 Challenges to networking 85 The networked manager and the isolated manager 88 Summary 89 viii NIHR Journals Library

11 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Chapter 7 Discussion 91 Introduction How do occupational backgrounds and careers affect knowledge receptivity, sharing and learning? 91 Clinical managers 91 General managers 92 Functional managers How do communities of practice enable/construct knowledge sharing and learning? Which mechanisms support knowledge receptivity, sharing and learning? 96 Chapter 8 Conclusion and recommendations 99 Effects of organisational and managerial diversity 99 Management and leadership in the health-care context 99 Knowledge, knowledge mobilisation and learning 100 Networks and communities of practice 101 Limitations and directions for future research 102 Recommendations 103 Acknowledgements 107 References 109 Appendix 1 Project flow chart 117 Appendix 2 Phase 1 key informant interview schedule 119 Appendix 3 Invitation letter 121 Appendix 4 Participant information sheet 123 Appendix 5 Project summary document 127 Appendix 6 Consent form 129 Appendix 7 Phase 2 interview schedule 131 Appendix 8 Full list of network events observed 133 Appendix 9 Thematic guide for observations 135 Appendix 10 Key NHS leadership training programmes 137 Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

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13 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 List of tables TABLE 1 Comparison of trust characteristics (end of project) 9 TABLE 2 Summary of sample by management group and by trust 13 TABLE 3 Gender distribution by trust and management group 13 TABLE 4 Age distribution by trust 13 TABLE 5 Average time (years) spent in post, in trust and in NHS 14 TABLE 6 Data collected 15 TABLE 7 Charting management changes in the NHS 20 TABLE 8 Summary of key NHS management and leadership training programmes 23 TABLE 9 Comparison of trust key characteristics 26 TABLE 10 Contrasting portrayals of management and leadership 40 TABLE 11 Mintzberg on managerial roles 48 TABLE 12 Clinical backgrounds and qualifications 60 TABLE 13 Advantages and disadvantages of experience and experiential learning 63 TABLE 14 Non-clinical educational qualifications 64 TABLE 15 Advantages and Disadvantages of Formal Training 68 TABLE 16 Typology of networks 75 TABLE 17 Dimensions of networks 75 Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

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15 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 List of figures FIGURE 1 NHS Management Model (final version) 10 FIGURE 2 Contextual factors by trust 25 FIGURE 3 Aspects of change by trust 26 FIGURE 4 Contextual factors at acute trust: number of interview references 28 FIGURE 5 Contextual factors at care trust: number of interview references 31 FIGURE 6 Contextual factors at specialist trust: number of interview references 33 FIGURE 7 Management roles and responsibilities: number of interview references 47 FIGURE 8 Management skills: number of interview references 49 FIGURE 9 Management skills interactions 51 FIGURE 10 Forms of knowledge and modes of learning 54 FIGURE 11 Levels of formal training by trust 67 FIGURE 12 Levels of formal training by management group 68 FIGURE 13 Networking motives: number of interview references 77 FIGURE 14 Networking motives by trust 77 FIGURE 15 Networking motives by management group 77 FIGURE 16 Networking motives by gender 78 FIGURE 17 Complementary motives for networking 84 Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

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17 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 List of abbreviations AHP CCG CHI allied health professional clinical commissioning group Commission for Health Improvement ICT IT MBA information and communication technology information technology Master of Business Administration CoP community of practice MSc Master of Science CQC DGH FT GMTS Care and Quality Commission district general hospital foundation trust Graduate Management Training Scheme NICE NoP PCT SDO National Institute for Health and Care Excellence network of practice primary care trust Service Delivery Organisation GP general practitioner SHA strategic health authority HR human resources Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

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19 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Plain English summary Given the demands facing NHS managers, it is important to know that they can access leading-edge management knowledge to improve health-care delivery and that this knowledge can be effectively translated into different health-care settings. Currently, we have only a limited understanding of how managers access and use management knowledge and how this is affected by the organisations they work for and the professional communities they relate to. This research sets out to fill these gaps in our understanding by exploring how managers in the NHS use knowledge and learning from various sources to apply to develop and improve management practice. In doing so, it recognises that NHS management is made up of various different groups, including clinical, functional and general managers, and that these groups may rely on different sources for guidance on how best to manage. The study also recognises that what managers perceive to be valuable management knowledge varies and is affected by their background, role and organisational practices. We interviewed 68 managers across three different types of trust in the NHS and observed their participation in different knowledge networks. Our research led us to differentiate between three broad groups of managers who represented very different experiences of management practice. We examined their various backgrounds and how this affected how they acquired and applied management knowledge. We also explored the networks they relied on in their daily practice. Our findings led us to make a number of recommendations regarding management development and organisational support. The main findings of the research stressed the highly diverse sources of knowledge, learning, experience and networks drawn upon by distinct management groups (clinical, general and functional), the particular challenges facing general managers in establishing a distinct professional identity based around a coherent managerial knowledge base, the strong tendency for managers knowledge to be more home grown (localised) and experiential (as opposed to abstract and codified) and the tendency for this to be reinforced through the difficulties facing general managers in being actively engaged in wider networks of professionals for knowledge sharing, learning and support. Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

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21 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Scientific summary Background Managerial capacity development is considered integral to the UK government s strategy for implementing programmatic change connected to public service modernisation, particularly within the modern NHS. Reform in the NHS has closely reflected some broader trends in the private economy as market-based and performance management incentives have been introduced and competition has increased. In this context, understanding how managers in the NHS access and use management knowledge to help improve organisational processes, and so promote better service delivery, is of pressing importance in health-care research. Given the expectations we have of managers in the NHS to improve performance in the face of constant pressures for change, and the grave consequences of poor management, it is important to know that managers are at the leading edge of thinking in management theory and research. For this, there is a pressing need for more research into the uptake of management research and innovative practice by NHS health-care managers and how this relates to their professional development as managers. Yet, despite a good deal of research that has begun to look in-depth at how managers in the NHS perform their roles, we have only limited understanding of how managers access management knowledge, how they interpret it and how they adapt and apply it in their own health-care settings. There is also very little research that has tried to understand how the use of management knowledge relates to managers individual learning and development and how this ties in with their own development as professional managers among different communities of practice (CoPs) across the NHS. Similarly, we know relatively little about how the managers organisational setting influences the ways in which managers access, make sense of, select, adapt and apply relevant management knowledge. Aims and objectives The aim of the research was to investigate how NHS middle managers encounter and apply management knowledge and to examine the factors [particularly organisational context, career background and networks of practice (NoPs)/CoPs] that facilitate or impede the acceptance of new management knowledge and its integration with practice in health-care settings. It recognised, of course, that there are different groups within management that have their own needs and perspectives and that draw upon different types of management knowledge (e.g. operational, financial), that management knowledge itself is often the subject of considerable debate (particularly when transferred from different contexts, such as the manufacturing industry) and that managers are part of wider communities and NoPs within the NHS and beyond that influence approaches to professional training and development. Following on from this were three specific objectives: 1. to establish how occupational background and career influence knowledge receptivity, knowledge sharing and learning among health-care managers 2. to examine how relevant CoPs enable or obstruct knowledge sharing and learning 3. to ascertain which mechanisms are effective in supporting knowledge receptivity, knowledge sharing and learning/unlearning within and across such communities. Therefore, the emphasis was on understanding flows of management knowledge and learning as heavily influenced by the social and organisational context within which managers and their work are embedded Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

22 SCIENTIFIC SUMMARY as these contextual influences were expected to have an important effect on the ways in which managers access and use management knowledge and how they apply it to their management practices. This study complemented and built on existing studies concerning managers ability and motivation to access and use management research, managers information seeking behaviour and managers use of evidence in making management decisions. By identifying modes of professionalisation in communities of practising health-care managers, the study further aimed to illuminate the realities of managerial practice in the middle reaches of health-care organisations. The project also complemented existing studies that have focused on managerial roles and behaviours. Methods Middle managers were here defined inductively as those who were defined as such in the organisation, part of a clear chain of line management and located with at least two hierarchical levels of management above and below them. Our approach aimed to capture the subtleties of how different groups of managers go about accessing and using management knowledge in their everyday work. We therefore adopted a comparative case study approach, allowing for the in-depth examination of important similarities and differences between and within cases and managerial communities. Three types of NHS trust were selected to provide variation in organisational context. These were selected to provide quite distinct cases with regard to the diversity of services provided and, consequently, the knowledge requirements faced by managers and the networks likely to be available to them. The three trusts were: 1. Acute trust, which offers a wide range of acute services centralised mainly in one location and covering a fairly limited (local) geographical area. 2. Care trust, which delivers a diverse range of mental health and community services with operations distributed in many locations over a large (regional) geographical area. 3. Specialist trust, which offers a limited range of specialist services mainly from one central location to patients spread across a very wide (regional and national) geographical area. To capture differences across managerial groups in each trust, a selection framework was developed in the early stages of the project that was refined as the project developed and allowed us to differentiate between cohorts of managers that could be selected in each trust on the basis of their managerial and clinical orientation. l l l Clinical: included those with managerial responsibilities in medical and nursing areas (e.g. clinical directors, modern matrons and lead nurses). Functional: included those within specialist areas such as finance, human resources (HR), marketing, information technology (IT) and estates. General: included service, operations and general managers. The main characteristics and derivation of this framework are explained in more detail in the methodology chapter. After an initial phase of the study involving interviews with 13 selected key informants (e.g. from NHS employers and NHS Confederation) and members of the project advisory group, the main empirical phase consisted of semistructured interviews with selected cohorts of managers combined with ethnographic observation methods. A purposive, non-random sample of approximately eight managers was identified for each of the three cohorts of managers in each trust, yielding a total target sample size of around 72 managers across the three trusts for interview (in the event, 68 were actually interviewed). With repeat visits and follow-on interviews, up to 100 interviews were planned. xx NIHR Journals Library

23 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Access to potential participants was arranged through each trust s lead collaborator and HR department. Selections were made on the basis of meeting the need to generate sufficient numbers of interviews in each broad group (clinical, general and functional) while allowing some variation in their work position and context (e.g. different clinical/functional specialism or service operations). This would allow appropriate analytical (as opposed to statistical) generalisation. The final sample actually consisted of 68 interviewees across the three trusts (20 at Acute, 25 at Care and 23 at Specialist). Interviews were semistructured and carried out by two members of the research team. They ranged across seven key themes, which included background information, occupation/career, leadership/management, knowledge, networks, organisational context and change. Interviews lasted between 1 and 2 hours (the majority lasting around 1.5 hours) and all were recorded and transcribed. When possible and appropriate, meetings and other forms of management event (e.g. training workshop) were also observed in cases in which these managers were involved and in which knowledge processes would be expected to be most critical. All interviews and observations followed a standard research protocol that was based on the explicit agreement of managers to be interviewed or observed. All the data collected were transcribed, collated and stored centrally for coding and analysis using NVivo 9 (QSR International, Warrington, UK) qualitative data analysis software. A coding frame was inductively developed and applied to the interview transcripts by two of the research team (to ensure inter-rater reliability). The coding framework was used to structure the analysis and presentation of the data into four areas: context (institutional and trust), management (including leadership), knowledge and networks. Results The first aim of our empirical research was to set the examination of management in context and this was achieved by situating management activity in the context of wider institutional processes and changes, and also in the context of the particular structures and cultures of the trust organisations of which they were a part. Our analysis of management then focused on three key features: the nature of management and leadership, the clinical managerial interface and the responsibilities and skills required of managers. In exploring conceptions of leadership, managers made a consistently clear distinction between visionary, strategic and transformative leadership (which was highly valued) and a more procedural, operational and bureaucratic approach to management (which tended to be denigrated). Our analysis then explored the ways in which managers responsibilities related to this emerging emphasis on leadership in practice. Our focus on the clinical managerial divide identified key differences in the nature of that divide within the three trusts as well as differences in the mechanisms used to bridge that divide (structural, relational or through personal embodiment). The analysis of managers responsibilities identified a highly diverse set of roles and skill requirements, but a common strong emphasis on interpersonal skills. Regarding knowledge, our analysis drew upon a classic differentiation between explicit and tacit forms of (management) knowledge and between abstract learning and learning that is situated in practice. This enables us to distinguish between different types of knowledge and learning in our study and how they may be translated into practice through processes of socialisation, externalisation, combination and internalisation. As well as charting the difficulties of translating abstract management knowledge (e.g. lean thinking) into practice, our study also highlighted the challenges of translating local and embodied solutions and innovations into generalisable and transferable knowledge. We were also able to identify particular barriers to this knowledge mobilisation process. The pros and cons of formal training and development, as opposed to more experiential forms of learning, were also examined. Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

24 SCIENTIFIC SUMMARY Our analysis also focused on the impact of the influential body of professional knowledge associated with clinicians, against which managerial knowledge and understanding is often juxtaposed. Management knowledge was often perceived to be in competition with, or judged against, the standards of medical bodies of knowledge. At the same time, as many of our managers were also (or had been) clinicians, the performance of their role often relied as much on their clinical or other professional knowledge and experience (and the credibility it gave them) as it did on their managerial know-how. Regarding networks, we considered the various NoPs and CoPs to which managers belonged and explored the diverse range of inter-related purposes served by networks, including not only knowledge acquisition but also career advancement, influencing policy and practice, and personal/emotional support. Striking in this regard was the variation that existed amongst groups of managers in their access to, and use of, networks for knowledge and support. Clinical and functional groups of managers had much greater access to wider networks and professional CoPs than did their counterparts in more general managerial roles. The comparative absence of wider networks for general managers to readily access and draw upon different forms of knowledge also reinforced the likelihood that existing ways of operating and managing would become self-reinforcing. In other words, managers were not only focused on responding to local managerial challenges but also more isolated than the other two groups from sources of knowledge and learning potentially accessed through networks of peers. Conclusions This research set out to investigate how NHS managers encounter and apply new management knowledge, examining the organisational and extra-organisational factors that facilitate or impede the acceptance of new management knowledge and its integration with practice in health-care settings. Our research differentiated between three broad groups of managers, in terms of their routes into management, roles and responsibilities, and their diverse orientations towards management knowledge, its acquisition, translation and application. The main findings of the research stress the heterogeneity of management and the highly diverse sources of knowledge, learning, experience and networks drawn upon by distinct management groups (clinical, general and functional), the particular challenges facing general managers in establishing a distinct professional identity based around a coherent managerial knowledge base, the strong tendency for managerial knowledge particularly that harnessed by general managers to be more home grown (localised) and experiential (as opposed to abstract and codified) and the tendency for this to be reinforced through the difficulties facing general managers in accessing and being actively engaged in wider networks of professionals for knowledge sharing, learning and support. The research underlines the challenges of overcoming fragmentation across a diffuse managerial CoP in health care, exacerbated by the effects of organisational complexity and differentiation. The research highlights the importance of specific training and development initiatives and also the value of NoPs for knowledge sharing and support of managers. Recommendations 1. Valuing management as well as leadership: the research points to a widespread tendency to denigrate management in favour of heroic conceptions of leadership. There are benefits to be gained from a clearer recognition of the contribution of effective management and the necessity of explicitly presenting management and leadership as equal partners in managing complex and changing organisations. xxii NIHR Journals Library

25 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO Balancing experiential learning: the research indicates that the challenge of codifying and translating management knowledge leads to an over-reliance on experience and localised, situated knowledge and/or a tendency to privilege other forms of knowledge such as clinical or financial. The evidence underlines the value of networks and other social modes of engagement to overcome these epistemic boundaries and assist the circulation of knowledge. 3. Facilitating clinical managerial relations: the challenge of managing the relationship between clinical and managerial communities is pervasive across health-care organisations. Our trusts each adopted distinct structural, relational, or personally embodied means to manage this relationship, each reflecting their organisational contexts. The research suggests that there is no universal solution and that trusts need to tailor their ways to manage this divide. 4. Enabling reflective learning: in light of the evidence on translation gaps in health-care organisations, our research suggests that receptivity to management knowledge, and the innovative or creative use of this knowledge, are enhanced by training and development that allows space and time for reflection and knowledge translation. This applies across all managerial groups but especially to general managers. 5. Encouraging strong network ties: the research indicates that networking for knowledge acquisition/ sharing, support, career-development and influence are closely inter-related. Therefore, recognition of the embeddedness of knowledge processes in social networks points to the importance of supporting the formation of strong network ties to enhance knowledge sharing and learning. 6. Extending general management networks: given the evidence pertaining to isolation and inward-looking tendencies among general management groups in health care, trusts may consider the advantages of providing greater opportunities for internal and external networking to assist knowledge sharing and learning. 7. Strengthening professional CoPs through leadership development: the research underlines the challenges posed by the extreme diversity of managers responsibilities and skills owing to task and organisational differentiation and the fragmentation this creates within managerial CoPs. This supports the value of a widely available management and leadership development programme that meets the needs of the whole spread of middle managers more effectively. Funding The National Institute for Health Research Health Services and Delivery Research programme. Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

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27 DOI: /hsdr02140 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 14 Chapter 1 Introduction Background to the research Understanding how managers in the NHS access and use management knowledge to help improve organisational processes and so promote better service delivery is of pressing importance in health-care research. 1 3 Given the expectations we have of managers in the NHS to improve performance in the face of constant pressures for change, and the grave consequences of poor management, 4 it is important to know that managers are at the leading edge of thinking in management theory and research. For this, it is key to understand how managers access ideas that can improve health-care delivery and are able to translate these effectively into a health-care setting. Yet, despite a good deal of research that has begun to look in-depth at how managers in the NHS perform their roles, we have only limited understanding of how managers access management knowledge, how they interpret it and how they adapt and apply it in their own health-care settings. 5 There is also very little research that has tried to understand how the use of management knowledge relates to managers individual learning and development, how this ties in with their own development as professional managers among different communities across the NHS. 6,7 Similarly, we know relatively little about how the organisational setting itself influences the ways in which managers access, make sense of, select, adapt and apply relevant management knowledge. 8 This research sets out to fill these gaps by exploring how middle managers in the NHS access knowledge and learning from various sources to apply, develop and improve management practice. In doing so, it recognises that there are different groups within management that have their own needs and perspectives and that draw upon different types of management knowledge (e.g. operational, financial), that management knowledge itself is often the subject of considerable debate (particularly when transferred from different contexts, such as manufacturing industry) and that managers are part of wider communities and networks of practice (NoPs) within the NHS and beyond that influence approaches to professional training and development. Aims and objectives The aim of the research is to investigate how NHS middle managers encounter and apply management knowledge and to examine the factors [particularly organisational context, career background and NoPs/communities of practice (CoPs)] that facilitate or impede the acceptance of new management knowledge and its integration with practice in health-care settings. Following on from this are three specific objectives: 1. to establish how occupational background and career influence knowledge receptivity, knowledge sharing and learning among health-care managers 2. to examine how relevant CoPs enable or obstruct knowledge sharing and learning 3. to ascertain which mechanisms are effective in supporting knowledge receptivity, knowledge sharing and learning/unlearning within and across such communities. The research therefore emphasises the importance of understanding flows of management knowledge and learning as heavily influenced by the social and organisational context within which managers and their work are embedded. 8,9 These contextual influences namely, their background and career development, the organisational settings in which managers operate, and the networks and communities Queen s Printer and Controller of HMSO This work was produced by Bresnen et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1